When SSRI Wears Off, Will Rages Subside?
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Q:  When SSRI Wears Off, Will Rages Subside?

Dr. Phelps,
My 12 yr old son, had a 4-6 week history of moodiness; sadness; lethargy; loss of energy; depressed; which eventually led to school avoidance; school refusal...my husband has bipolar...we saw a psychologist, who recommended a psych eval..the psych MD started Zoloft and xanax for anxiety...after 4wks on zoloft, he continued to get worse...he was no longer able to go to school; he would not come out of his room...refused to change clothes; brush teeth etc...at 4 wks on zoloft; the psychiatrist said we should consider a mood stabilizer (trileptal along with xanax), since his symptoms have worsened, and see what that does...especially with family hx of bipolar.  we started trileptal/ dc'd zoloft, and during this time, he started "raging" going into a rage of anger and frustration; throwing things in his room; punching the walls...and worse, refusing all treatment, meds and therapy....after being on several websites and reviewing the FDA warning on SSRIs; i am convinced this is a SSRI induced mania...my  question is:  he is refusing any medications...how long cani expect the rages to continue?  ...if they are a result of the zoloft, is there a chance the raging will subside after the SSRI effect wears off, without any treatment?  ...I hate to proceed with involuntary hospitalization for my precious son, during his rages, he is vicious toward me, blaming me directly for all that has happened, and he no longer trusts me and any communication has shut down.....

Dear Ms. B -- 
As many mothers might feel they should, you sound as though you are personally taking responsibility for deciding things like whether he should get hospitalized.  So let me begin by reminding you that you may also use the doc's you get involved to help make that decision, and that some people might even just turn that decision over to the doctor and her/his staff (e.g. including an inpatient team).  Not that you should or have to, but you could..  In other words, you don't have to figure this out yourself, alone; it might even be better not to.  Just in case that's what you feel like you must do, as again I think is entirely understandable. 

As for whether Zoloft caused this episode, or whether things were headed this way anyway; or whether Zoloft might have accelerated or triggered  something; or even whether it might have been the stopping of Zoloft that is associated with the current worsening (so called "antidepressant-discontinuation-induced mania"); it would be impossible to be certain.  We face the same dilemma when someone comes in to the hospital after using cocaine or methamphetamine, and they're manic:  was it from the drugs?  would it have been happening anyway?  

And how long can one expect symptoms to continue?  How about if we somehow magically knew for certain that the Zoloft or its discontinuation was the cause?  Even then we can not answer this second question either.  Perhaps an underlying potential for worsening was triggered and will now go forward on its own; or perhaps after a period of time, things will settle down and no medication would be needed to prevent recurrence either (a third question that may come up down the road).  Sorry to be so useless in addressing your obviously important questions. 

Dr. Phelps

Published September, 2004


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